Why do people co-use benzodiazepines and opioids? Opening the question to the forum, Bristol Medical School’s Dr Jenny Scott said it was important to try to understand motivation, particularly when looking at care of vulnerable people – and because most drug-related deaths involved polydrug use. A study involving 48 people who had overdosed in Glasgow, Bristol and Teesside had given insight.
On one hand benzo use could be called functional – to feel calm or give confidence, rather than to deliberately feel intoxicated. The other scenario was more experimental – to feel a buzz, a warm glow, a feeling of intoxication: ‘Benzos took them into oblivion, away from all their problems.’
Many people were bingeing, using handfuls of street benzos in uncontrolled quantities, and often using opioids and benzos together, she explained. The changing patterns of co-use could be triggered by prescribing decisions or the change in availability of illicit drugs, and could veer from controlled use to a much more chaotic situation.
So what was the perception of overdose risk? ‘People were acutely aware of consumption roulette, where they’re not sure what they’re going to get,’ said Scott. ‘At times they were asking “how can I keep myself safe?”.’ Attempts to try to do so included taking one dose every five minutes, then another – not failsafe as the effects could take longer to kick in – but it was at least evidence of a strategy, she said. Others experienced hopelessness and inability to change – ‘it’ll probably kill me’ – particularly if they had been severely affected by trauma.
Lack of care could make people feel ‘horrible’ about themselves and give them a sense of not being able to go anywhere for help. And while some people felt able to do things to keep themselves safe, others were made additionally vulnerable by their lack of stability and inability to manage triggers such as arguments with family members. The findings pointed to a ‘huge unmet need for mental health support,’ said Scott.
People’s understanding of street benzos was found to be ‘quite limited’, especially where there was co-use with other drugs. As most overdoses were unintentional, there was a clear need for consumption rooms and drug-checking initiatives, she said. Furthermore, the different cohorts and uses relating to street benzos and prescribed benzos needed very different interventions.
‘When you come to work you don’t know what you’re going to deal with that day,’ said a member of the Sheffield Working Women’s Opportunities Project (SWWOP), represented by Shelley Jackson, Sophie Golland and Lydia Flower. What was clear was the group’s success in providing a safe space and trauma-informed support in a red light district of Sheffield – ‘a vital link between marginalised women and wider health and social support services’. The SWWOP staff had realised they were uniquely placed to see opportunities for early intervention, especially as the women they came into contact with ‘often fall down the gap of care’.
The team was proud to collaborate on a holistic trauma-informed health care model, and there was a sense of ownership and pride to be part of the project from all involved. ‘It’s a safe space and it’s important for us to feel that trust,’ said Rosie, one of the women who attended the service, in an audio clip. It was a refuge ‘from the chaos’ and gave opportunities to improve physical health and enhance wellbeing, as well as having a long-term impact on integrated healthcare.
A pilot scheme offering long-acting buprenorphine had given hope to those who might have struggled to maintain their script because of irregular hours. It had given the team the chance to signpost them to other services, including respiratory health (especially COPD), overall health and wellbeing, sexual health and harm reduction interventions.
Key to progress had been partnering with the Wicker Pharmacy in Sheffield, which was in the right location – a space where the women felt safe and secure. Supported by a drug worker and a GP, they were able to focus on five key aims – easier access to drug treatment, sexual health support, scripts, mental health and wellbeing interventions, and easier access to healthcare. ‘We wanted to improve physical health, enhance wellbeing, and have a long-term impact on integrated healthcare,’ said Lydia Flower.
Feedback from the long-acting buprenorphine trial was showing very positive results so far: ‘It’s changed my life massively – it’s calmed me down,’ LJ, a visitor to the service, had told the team. ‘I’m already making plans for the future. Even that bit of itchy pain you get afterwards is worth it for what you get from it.’
‘It’s changing my other drug use,’ said another, Jo. ‘It’s gone down to two days now. I’ll put it this way – I haven’t been drug-free since the age of 11… If this is normal, I love it.’
What is alcohol-related brain damage (ARBD), what does it do and how does it present? Julia Lewis from the University of South Wales looked at what could be done for patients who might be drinking heavily – from the first stages of their treatment onward.
‘Umbrellas, spectrums and syndromes’, the subject of a chapter in the forthcoming alcohol guidelines, explained how a collection of neurocognitive syndromes overlapped ‘because people normally have more than one of them’. The biggest group happened in the frontal lobe.
So what caused ARBD? ‘Booze gets into the bloodstream and into the brain quickly,’ she explained. ‘The immune system mounts its attack on its own tissue.’ Glutamate caused damage to brain cells – the areas of white matter and the insulation around brain fibres. ‘You need lots of thiamine to repair it.’ If the insulation was damaged, you could do something about it – but once the axiom was damaged you couldn’t do much.
The body turned thiamine over quite quickly and needed it to replenish, she said. Alcohol stopped this from happening. Damage could be repaired if there was enough thiamine, and in withdrawal it was needed acutely – without it at this stage there was risk of acute brain damage.
Classic symptoms of ARBD ranged from short-term memory impairment to retrograde amnesia. Confabulations were commonly experienced – when the brain tried to make sense of the situation the person was in by constructing a situation that might be far from reality, but trying to make sense of the information it had.
‘Memory impairment and dementia – we’re used to talking about this,’ said Lewis. ‘But dysexecutive syndrome gets overlooked’ – this could involve poor motivation, difficulties with planning, goal-setting, control, flexibility and thinking. A lot of doctors didn’t know much about ARBD, she said, while getting a good social worker who was interested in it could be ‘a godsend’.
A study of 300 consecutive cases showed that drinking more than 50 units for men and 35 units for women for more than five years put you at risk of ARBD. ‘You can stop cognitive decline if you come off the booze,’ she said. ‘If you’ve drunk enough to damage your liver, you’ve probably drunk enough to damage your brain.’
Gradual decline could be reversed to become gradual improvement over three years. Alongside medication, the other aids to recovery were cognitive programmes, family and friends, and the right accommodation and support. A transition phase – at home with support – required assessment and reassessment throughout, which was why ‘you need a good social worker onboard’.
Managing the situation involved all aspects of routine – the right nutrition, a regular bedtime, developing relationships and bringing family and friends into the therapeutic process. ‘A lot of what we need is out there – we’re just not used to working with ARBD,’ she said. ‘We need to look at what services are out there and how they could work together.’